=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821433525
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. LIA M LAINE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2013
-----------------------------------------------------
Last Update Date | 04/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 890 ELM GROVE RD VILLAGE COURT BUILDINGS SUITE #205
-----------------------------------------------------
City | ELM GROVE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53122-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-780-0991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 890 ELM GROVE RD SUITE 205
-----------------------------------------------------
City | ELM GROVE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53122-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4975-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------